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The Institute for Attachment and Child Development “Achieving Permanency For Children Diagnosed With Reactive Attachment Disorder” Presented by: Forrest R. Lien, LCSW-Director Email: [email protected] P.O. Box 730 – Kittredge, CO 80457 (303) 674-1910-phone (303) 670-3983-Fax www.InstituteForAttachment.org Attachment Cycles 1st Year Necessary ingredients of development of basic trust and attachment: Need Relaxation of Tension (trust) Trust Of Caretaking Satisfaction of Need (gratification) State of High Arousal (rage) • • • • • • • Eye Contact Food Motion Touch Verbal Contact Emotional Contact Smiles Attachment Cycles 2nd Year Wants Mutual good Feelings Trust Of Control Acceptance Of Limits TRUST State of High Arousal (rage) Necessary ingredients of development of autonomy, good character foundation and conscience. Maintain parental control while allowing child to explore and begin to make good choices for themselves. AUTONOMY ATTACHMENT Sub-Types of Attachment Disorder 1. AVOIDANT-isolation, avoid closeness, seldom seek comfort, avoid relationships, passive-aggressive, avoid feelings, intense sadness and loneliness, believe their rejection by birth mom was justified 2. ANXIOUS-crazy liars, fake emotions, emotionally empty, “good actors”, chameleons, often fool therapists that they’re normal and parents aren’t 3. DISORGANIZED-disorganized, odd, and bizarre behaviors. Other psychiatric disorders, unpredictable moods, excessively excitable, frequent sensory or neurological problems, difficult to manage 4. AMBIVALENT-openly angry, defiant, destructive, dangerous, superficially charming, lack of empathy, delinquent acts, most prevalent subtype in mental health systems Brain Organization/Development simple to complex Brain is responsible for : Survival/Biological responses, i.e. • • • • Heart rate Temperature Blood pressure Arousal states Limbic/Midbrain responsible for: • • • Emotion Attachment Affect regulation Cortex is responsible for: • • Abstract reasoning Complex language Brainstem (arrives hard-wired and online) Limbic/Midbrain (carries blue-print only) Cortex (arrives blue-print only) Abuse Traumatic Event (Physical, Sexual abuse) Domestic violence Release of Stress-Based Hormones (catecholamine) PROLONGED ALARM REACTION AROUSAL CONTINUUM Normal stress Response is reversible DISSOCIATIVE CONTINUUM Two distinct neuronal response patterns “adaptive style” ALTERED BRAIN DEVELOPMENT “STATES BECOME TRAITS” Sensitized to external cues Causes Any of the following conditions put a child at high risk of developing an attachment disorder. The critical period is from conception to about twenty-six months of age. • • • • • • • • • • • Genetic predisposition Maternal ambivalence toward pregnancy Traumatic prenatal experience, in-utero exposure to alcohol/drugs Birth trauma Sudden separation from primary caretaker ( i.e. illness or death of mother or sudden illness or hospitalization of child.) Undiagnosed and/or painful illness, such as colic or ear infections Inconsistent or inadequate day care Unprepared mothers with poor parenting skills Abuse ( physical, emotional, sexual) Neglect Frequent moves and/or placements ( foster care, failed adoptions) ABUSIVE BIRTH PARENTS AND PSYCHIATRIC DIAGNOSIS 1. ANTISOCIAL (SOCIOPATHIC) PERSONALITY DISORDER Many of the diagnostic characteristics of children with Reactive Attachment Disorder also fit adult characteristics of Antisocial Personality Disorder. These include substantial conduct disorders including cruelty to people or animals, lying, stealing, fire setting, failure to conform to social norms, irritability, aggressively and impulsivity. These people have little regard for the truth, and lack empathy and remorse. Many of these adults were themselves abused or neglected in early childhood. 2. BORDERLINE PERSONALITY DISORDER 3. PARANOID SCHIZOPHRENIA is a complex disorder, usually strongly genetically influenced and is The etiology of Borderline Personality Disorder is not well understood, but there is evidence of both genetic and psychological influences, to some degree attributable to poor parenting (neglect or over-protective) between birth and three years of age. Borderline Personality Disorder manifests as long-term patterns of unstable mood, interpersonal relationships and self image. characterized by though disturbances such as delusions and hallucinations. In a delusional or hallucinatory state they are capable of abuse or neglect, though uncommonly. 4. ALCOHOL/SUBSTANCE ABUSE In my experience working with abused kids, this is the single most common characteristic of abusing parents,. However, in my experience, it is also most commonly a coexistent factor of abuse. In other words, while alcohol and substance abusing parents may abuse their children, it is usually of less severity and is usually not in an ongoing manner. Purely alcohol or substance abusing parents who over-indulge and neglect or abuse their children are ordinarily regretful and remorseful of their actions. 5. BIPOLAR DISORDER This is a common psychiatric mood disorder representing 2 to 3 percent of the general population. It is a genetic, inherited, familial disorder that ultimately results in biochemical imbalances within one’s central nervous system. It manifests in manic (or hypomanic, a lesser form of manic) and/or depressive mood disturbances. In my professional experience, this is by far the disorder that has the greatest coincidence with abuse or neglect of children and as such is the genetic disorder that these children with coexistent Reactive Attachment Disorder also inherit. The degree of self-centeredness, irritability and intensity of rage reactions while in a manic state is frequently sufficient to create severe abusive conditions. Correspondingly, the degree of profound depression is likewise severe and prolonged enough to create long standing neglectful circumstances. Symptoms of Attachment Disorder • • • • • • • • • • • • • • • • • • Superficially engaging, charming (phoniness) Lack of eye contact Indiscriminately affectionate with strangers Lacking ability to give and receive affection (not cuddly on parents terms) Extreme control problems: often manifest in covert or “sneaky” ways Destructive to self, others, things Cruelty to animals Chronic lying No impulse controls Learning lags and disorders Lacking cause and effect thinking Lack of conscience Abnormal eating patterns Poor peer relationship Preoccupied nonsense questions and incessant chatter Inappropriately demanding and clingy Abnormal speech patterns Parents appear unreasonably hostile and angry Characteristics of Attention Deficit Disorder, Bipolar Disorder, and Reactive Attachment Disorder John F. Alston, M.D., P.C. Website: www.johnalstonmd.com Symptoms Age of Onset Family History Lifelong Prevalence Etiology Attention Deficit Disorder Bipolar Disorder Reactive Attachment Disorder Infancy to toddler, 6 years, 13 years 2 to 3 years, 6 years, 13 to 25 years Birth to 3 years ADHD, academic difficulties (based on task incompletion), alcohol and substance abuse Any mood disorder (depression or bipolar), academic difficulties (based on motivation problems or opposition or defiance), alcohol and substance abuse, adoption, ADHD Abuse and neglect, severe emotional and behavior disorders, alcohol, and substance abuse. Abuse neglect in parents’ own early life 3 to 6 % general population 3 to 5 % of general population Uncommon to common Genetic, Neurochemical, fetal development, brain traumas, nutritional deficiencies, exacerbated by stress Genetic, exacerbated by stress and hormones Psycho physiologic secondary to neglect, abuse, mistreatment, abandonment WORKING WITH PARENTS Assess the developmental level and needs of parents. 1. 2. 3. Intact at-risk family – child remains in abusive situation. a. High incidence of parents with poor attachment histories of their own. b. All of the qualities of unattached children still present in grown up form. c. Not available for education (cortex). Foster families. a) Assess availability for work of attachment. b) Impact of personal trauma history – usually not explored. Adoptive families. a) Education re: attachment and trauma b) Family of origin history will become important and needs to be explored over time. c) Respite !!!! Post Traumatic Stress in Parents Causes Repeated rejections by child – giving and giving with little or no lasting positive return Relentless, unending control battles – need for incredible selfcontrol at all times Changes within yourself & family that seem out of your control & are not apparent choices Primary Symptoms Avoidance of thoughts & feeling,, decreased interest & participation in significant events Feeling that you are unlike Others, damaged sense of self-worth, feeling out of control of emotion Psychological/Physical distress at exposure to trigger events that symbolize the trauma Decreased affect & display of feelings, sense of being detached or estranged from others Secondary Symptoms & Effects Selectivity in perceptions, victim identity, fatigue and depression, loss of security Increase arousal sleep problems, Irritable, angry, hyper vigilance, higher startle response Helplessness Hopelessness Anger RAGE TREATMENT FOSTER CARE: Developmental Model . A) Creating a circle of security in a family setting -Line of site safety-developmental circle of security with environmental controls -Parents direct and redirect -Children learn life skills living in a family i.e. doing chores, learning respectful communication, cooperative play, build self-confidence -Learn to trust that adults will keep you safe-children give up control B) Skilled attachment therapist leads the team - Empathic confrontation – therapist is coach/guide, providing balance of challenge and support C) Creating a circle of community support -school, police, caseworkers D) Psychiatric Care and Neurofeedback E) Working with Attachment Figure i.e. relative, adoptive parent, foster parent -creating safety with attachment figure by helping with emotional triggers, parent training, attachment therapy